2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain PDF

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain Endorsed by the American Society of Echocardiography, American College of Chest Physicians, Society for Academic Emergency Medicine, Society of Cardiovascular Computed Tomography, an...

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain Endorsed by the American Society of Echocardiography, American College of Chest Physicians, Society for Academic Emergency Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance  Citation This slide set is adapted from the 2021 AHA/ACC Guideline for the Evaluation and Diagnosis of Chest Pain. Published online ahead of print October 29, 2021, available at: Circulation. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001029 and Journal of the American College of Cardiology published online ahead of print October 29, 2021. J Am Coll Cardiol. https://doi.org/10.1016/j.jacc.2021.07.053  2021 Writing Committee Members* Martha Gulati, MD, MS, FACC, FAHA, Chair† Phillip D. Levy, MD, MPH, FACC, FAHA, Vice Chair † Debabrata Mukherjee, MD, MS, FACC, FAHA, Vice Chair† Ezra Amsterdam, MD, FACC† Erik P. Hess, MD, MSc† Deepak L. Bhatt, MD, MPH, FACC, FAHA† Steven M. Hollenberg, MD, FACC, FAHA, FCCP†† Kim K. Birtcher, MS, PharmD, AACC‡ Wael A. Jaber, MD, FACC, FASE‡‡ Ron Blankstein, MD, FACC, MSCCT § Hani Jneid, MD, FACC, FAHA§§ Jack Boyd, MD† José A. Joglar, MD, FAHA, FACC‡ Renee P. Bullock-Palmer, MD, FACC, FAHA, FASE, David A. Morrow, MD, MPH, FACC, FAHA† FSCCT† Robert E. O’Connor, MD, MPH, FAHA† Theresa Conejo, RN, BSN, FAHA║ Michael A. Ross, MD, FACC† Deborah B. Diercks, MD, MSc, FACC¶ Leslee J. Shaw, PhD, FACC, FAHA, MSCCT† Federico Gentile, MD, FACC# John P. Greenwood, MBChB, PhD, FSCMR, FACC** *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡ ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison. §Society of Cardiovascular Computed Tomography Representative. ║ Lay Patient Representative. ¶Society for Academic Emergency Medicine Representative. #Former ACC/AHA Joint Committee member; current member during the writing effort. **Society for Cardiovascular Magnetic Resonance Representative. ††American College of Chest Physicians Representative. ‡‡American Society of Echocardiography Representative. §§Task Force on Performance Measures, Liaison.  Top 10 Take-Home Messages 2021 Evaluation and Diagnosis of Chest Pain 4  Top 10 Take Home Messages 1. Chest Pain Means More Than Pain in the Chest. Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue should all be considered anginal equivalents. 5  Top 10 Take Home Messages 2. High-Sensitivity Troponins Preferred. High-sensitivity cardiac troponins are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury. 6  Top 10 Take Home Messages 3. Early Care for Acute Symptoms. Patients with acute chest pain or chest pain equivalent symptoms should seek medical care immediately by calling 9-1-1. Although most patients will not have a cardiac cause, the evaluation of all patients should focus on the early identification or exclusion of life-threatening causes. 7  Top 10 Take Home Messages 4. Share the Decision-Making. Clinically stable patients presenting with chest pain should be included in decision- making; information about risk of adverse events, radiation exposure, costs, and alternative options should be provided to facilitate the discussion. 8  Top 10 Take Home Messages 5. Testing Not Needed Routinely for Low-Risk Patients. For patients with acute or stable chest pain determined to be low risk, urgent diagnostic testing for suspected coronary artery disease is not needed. 9  Top 10 Take Home Messages 6. Pathways. Clinical decision pathways for chest pain in the emergency department and outpatient settings should be used routinely. 10  Top 10 Take Home Messages 7. Accompanying Symptoms. Chest pain is the dominant and most frequent symptom for both men and women ultimately diagnosed with Acute Coronary Syndrome. Women may be more likely to present with accompanying symptoms such as nausea and shortness of breath. 11  Top 10 Take Home Messages 8. Identify Patients Most Likely to Benefit From Further Testing. Patients with acute or stable chest pain who are at intermediate risk or intermediate to high pre-test risk of obstructive coronary artery disease, respectively, will benefit the most from cardiac imaging and testing. 12  Top 10 Take Home Messages 9. Noncardiac Is In. Atypical Is Out. “Noncardiac” should be used if heart disease is not suspected. “Atypical” is a misleading descriptor of chest pain, and its use is discouraged. 13  Top 10 Take Home Messages 10. Structured Risk Assessment Should Be Used. For patients presenting with acute or stable chest pain, risk for coronary artery disease and adverse events should be estimated using evidence-based diagnostic protocols. 14 Figure 1. Take-Home Messages for the Evaluation and Diagnosis of Chest Pain 15 Table 1. ACC/AHA Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019) 16 Defining Chest Pain 17  Defining Chest Pain Recommendations for Defining Chest Pain Referenced studies that support the recommendations are summarized in Online Data Supplements 1 and 2. COR LOE Recommendations 1. An initial assessment of chest pain is recommended to triage patients effectively on the basis 1 B-NR of the likelihood that symptoms may be attributable to myocardial ischemia. 2. Chest pain should not be described as atypical, because it is not helpful in determining the cause and can be misinterpreted as benign in nature. Instead, chest pain should be described 1 C-LD as cardiac, possibly cardiac, or noncardiac because these terms are more specific to the potential underlying diagnosis. 18 Figure 2. Index of Suspicion That Chest “Pain” Is Ischemic in Origin on the Basis of Commonly Used Descriptors. 19 Initial Evaluation 20  History Recommendation for History COR LOE Recommendation 1. In patients with chest pain, a focused history that includes characteristics and duration of symptoms relative to presentation 1 C-LD as well as associated features, and cardiovascular risk factor assessment should be obtained. 21 Figure 3. Top 10 Causes of Chest Pain in the ED Based on Age (Weighted Percentage). Created using data from Hsia RY, et al. (3). 22  Table 3. Chest Pain Characteristics and Corresponding Causes Nature Anginal symptoms are perceived as retrosternal chest discomfort (e.g., pain, discomfort, heaviness, tightness, pressure, constriction, squeezing) (Section 1.4.2, Defining Chest Pain). Sharp chest pain that increases with inspiration and lying supine is unlikely related to ischemic heart disease (e.g., these symptoms usually occur with acute pericarditis). Onset and duration Anginal symptoms gradually build in intensity over a few minutes. Sudden onset of ripping chest pain (with radiation to the upper or lower back) is unlikely to be anginal and is suspicious of an acute aortic syndrome. Fleeting chest pain—of few seconds’ duration—is unlikely to be related to ischemic heart disease. Location and radiation Pain that can be localized to a very limited area and pain radiating to below the umbilicus or hip are unlikely related to myocardial ischemia. 23  Table 3. Chest Pain Characteristics and Corresponding Causes (con’t.) Severity Ripping chest pain (“worse chest pain of my life”), especially when sudden in onset and occurring in a hypertensive patient, or with a known bicuspid aortic valve or aortic dilation, is suspicious of an acute aortic syndrome (e.g., aortic dissection). Precipitating factors Physical exercise or emotional stress are common triggers of anginal symptoms. Occurrence at rest or with minimal exertion associated with anginal symptoms usually indicates ACS. Positional chest pain is usually nonischemic (e.g., musculoskeletal). Relieving factors Relief with nitroglycerin is not necessarily diagnostic of myocardial ischemia and should not be used as a diagnostic criterion. Associated symptoms Common symptoms associated with myocardial ischemia include, but are not limited to, dyspnea, palpitations, diaphoresis, lightheadedness, presyncope or syncope, upper abdominal pain, or heartburn unrelated to meals and nausea or vomiting. Symptoms on the left or right side of the chest, stabbing, sharp pain, or discomfort in the throat or abdomen may occur in patients with diabetes, women, and elderly patients. ACS indicates acute coronary syndrome. 24  A Focus on the Uniqueness of Chest Pain in Women Recommendations for a Focus on the Uniqueness of Chest Pain in Women Referenced studies that support the recommendations are summarized in Online Data Supplements 3 and 4. COR LOE Recommendations 1. Women who present with chest pain are at risk for underdiagnosis, and potential cardiac causes should always be considered. 1 B-NR 2. In women presenting with chest pain, it is recommended to obtain a history that 1 B-NR emphasizes accompanying symptoms that are more common in women with ACS. 25  Considerations for Older Patients With Chest Pain Recommendation for Considerations for Older Patients With Chest Pain COR LOE Recommendation 1. In patients with chest pain who are >75 years of age, ACS should be considered when accompanying symptoms such as shortness of breath, syncope, or acute delirium are present, or when an unexplained fall has 1 C-LD occurred. 26  Considerations for Diverse Patient Populations With Chest Pain Recommendations for Considerations for Diverse Patient Populations With Chest Pain COR LOE Recommendations 1. Cultural competency training is recommended to help achieve the best outcomes in patients of diverse 1 C-LD racial and ethnic backgrounds who present with chest pain. 2. Among patients of diverse race and ethnicity presenting with chest pain in whom English may not be 1 C-LD their primary language, addressing language barriers with the use of formal translation services is recommended. 27  Patient-Centric Considerations Recommendation for Patient-Centric Considerations COR LOE Recommendation 1. In patients with acute chest pain, it is recommended that 9-1-1 be activated by patients or bystanders to initiate transport to the closest ED 1 C-LD by emergency medical services (EMS). 28  Physical Examination Recommendation for Physical Examination COR LOE Recommendation 1. In patients presenting with chest pain, a focused cardiovascular examination should be performed initially to aid in the diagnosis of ACS or other 1 C-EO potentially serious causes of chest pain (e.g., aortic dissection, PE, or esophageal rupture) and to identify complications. 29  Clinical Syndrome Findings Emergency ACS Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3, MR Table 4. murmur; examination may be normal in uncomplicated cases Physical Examination in Patients PE Tachycardia + dyspnea—>90% of patients; pain with inspiration With Chest Pain ACS indicates acute Aortic dissection Connective tissue disorders (e.g., Marfan syndrome), extremity pulse coronary syndrome; AR, aortic differential (30% of patients, type A>B) regurgitation; AS, aortic stenosis; CXR, Severe pain, abrupt onset + pulse differential + widened mediastinum on chest x-ray; LR, likelihood ratio; HCM, hypertrophic CXR >80% probability of dissection cardiomyopathy; MR, mitral regurgitation; Frequency of syncope >10% (8), AR 40%–75% (type A) PE, pulmonary embolism; and PUD, peptic ulcer disease. Esophageal rupture Emesis, subcutaneous emphysema, pneumothorax (20% patients), unilateral decreased or absent breath sounds 30  Other Noncoronary cardiac: AS, AR, AS: Characteristic systolic murmur, tardus or parvus carotid pulse HCM AR: Diastolic murmur at right of sternum, rapid carotid upstroke HCM: Increased or displaced left ventricular impulse, prominent a wave in jugular Table 4. Physical venous pressure, systolic murmur Examination in Patients Pericarditis Fever, pleuritic chest pain, increased in supine position, friction rub With Chest Myocarditis Fever, chest pain, heart failure, S3 Pain (con’t.) ACS indicates acute coronary syndrome; Esophagitis, peptic ulcer disease, Epigastric tenderness AR, aortic gall bladder disease Right upper quadrant tenderness, Murphy sign regurgitation; AS, aortic stenosis; CXR, chest x-ray; LR, Pneumonia Fever, localized chest pain, may be pleuritic, friction rub may be present, regional likelihood ratio; dullness to percussion, egophony HCM, hypertrophic cardiomyopathy; MR, Pneumothorax Dyspnea and pain on inspiration, unilateral absence of breath sounds mitral regurgitation; PE, pulmonary embolism; and PUD, Costochondritis, Tietze syndrome Tenderness of costochondral joints peptic ulcer disease. Herpes zoster Pain in dermatomal distribution, triggered by touch; characteristic rash (unilateral and dermatomal distribution) 31  Setting Considerations Recommendations for Setting Considerations Referenced studies that support the recommendations are summarized in Online Data Supplement 5. COR LOE Recommendations 1. Unless a noncardiac cause is evident, an ECG should be performed for patients seen in the office setting with stable chest pain; if an ECG is unavailable the patient should be 1 B-NR referred to the ED so one can be obtained. 2. Patients with clinical evidence of ACS or other life-threatening causes of acute chest pain seen in the office setting should be transported urgently to the ED, ideally by EMS. 1 C-LD 32  Setting Considerations (con’t.) 3. In all patients who present with acute chest pain regardless of the setting, an ECG should be acquired and reviewed for STEMI within 10 minutes of arrival. 1 C-LD 4. In all patients presenting to the ED with acute chest pain and suspected ACS, cTn should be measured as soon as possible after presentation. 1 C-LD 5. For patients with acute chest pain and suspected ACS initially evaluated in the office setting, delayed transfer to the ED for cTn or other diagnostic testing should 3: Harm C-LD be avoided. 33  Electrocardiogram Recommendations for Electrocardiogram (ECG) Referenced studies that support the recommendations are summarized in Online Data Supplement 6. COR LOE Recommendations 1. In patients with chest pain in which an initial ECG is nondiagnostic, serial ECGs to detect potential 1 C-EO ischemic changes should be performed, especially when clinical suspicion of ACS is high, symptoms are persistent, or the clinical condition deteriorates. 2. Patients with chest pain in whom the initial ECG is consistent with an ACS should be treated 1 C-EO according to STEMI and NSTE-ACS guidelines. 3. In patients with chest pain and intermediate-to-high clinical suspicion for ACS in whom the initial 2a B-NR ECG is nondiagnostic, supplemental electrocardiographic leads V7 to V9 are reasonable to rule out posterior MI. 34  Figure 4. Electrocardiographic- Directed Management of Chest Pain. ECG indicates electrocardiogram; NSTE-ACS, non–ST- segment–elevation acute coronary Colors correspond syndrome; MI, myocardial infarction; to the Class of and STEMI, ST-segment Recommendation elevation myocardial in Table 1. infarction. 35  Chest Radiography Recommendation for Chest Radiography COR LOE Recommendation 1. In patients presenting with acute chest pain, a chest radiograph is useful to evaluate for other potential cardiac, pulmonary, and 1 C-EO thoracic causes of symptoms. 36  Biomarkers Recommendations for Biomarkers Referenced studies that support the recommendations are summarized in Online Data Supplement 7. COR LOE Recommendations 1. In patients presenting with acute chest pain, serial cTn I or T levels are useful to identify abnormal values and a rising or falling pattern indicative of acute myocardial injury (1-21). 1 B-NR 2. In patients presenting with acute chest pain, high-sensitivity cTn is the preferred biomarker because it enables more rapid detection or exclusion of myocardial injury and increases 1 B-NR diagnostic accuracy (17, 21-25). 37  Biomarkers (con’t.) 3. Clinicians should be familiar with the analytical performance and the 99th percentile upper reference limit that defines myocardial injury for the cTn assay 1 C-EO used at their institution. 4. With availability of cTn, creatine kinase myocardial (CK-MB) isoenzyme and 3: No B-NR myoglobin are not useful for diagnosis of acute myocardial injury. benefit 38 Cardiac Testing General Considerations 39  Figure 5. Chest Pain and Cardiac Testing Considerations. The choice of imaging depends on the clinical question of importance, to either a) ascertain the diagnosis of CAD and define coronary anatomy or b) assess ischemia severity among patients with an expected higher likelihood of ischemia with an abnormal resting ECG or those incapable of performing maximal exercise. ACS indicates acute coronary syndrome; CAC, coronary artery calcium; CAD, coronary artery disease; and ECG, electrocardiogram. Please refer to Section 4.1. For risk assessment in acute chest pain: See Figure 9. For risk assessment in stable chest pain: See Figure 11. 40  Figure 6. Choosing the Right Diagnostic Test. ASCVD indicates atherosclerotic cardiovascular disease; CAD, coronary artery disease; CAC, coronary artery calcium; CCTA, coronary computed tomography angiography; CMR, cardiovascular magnetic resonance; LV, left ventricular; MPI, myocardial perfusion imaging; and PET, positron emission tomography. 41  Table 5. Contraindication by Type of Imaging Modality and Stress Protocol Exercise ECG Stress Nuclear (1)* Stress Echocardiography (2-4) Stress CMR (5) CCTA (6)*  Abnormal ST changes on resting ECG,  High-risk unstable angina, complicated ACS or  Limited acoustic windows (e.g., in COPD patients)  Reduced GFR (